A dollar limitation on the total amount of specified benefits that may
be paid under a group health plan (or group health insurance coverage offered
in connection with such a plan) for an individual (or for a group of individuals
considered a single unit in applying this dollar limitation, such as a family or
an employee plus spouse).

With respect to benefits under a group health plan or health insurance coverage, a
dollar limitation on the total amount of benefits that may be paid with respect
to such benefits in a 12-month period under the plan or health insurance
coverage with respect to an individual or other coverage unit.

An individual who is licensed under applicable State law to provide maternity or pediatric care and who is directly responsible for providing such care to a mother or newborn child. Therefore, a plan, hospital, managed care organization, or other issuer is not an attending provider. However, a nurse midwife or a physician assistant may be an attending provider if licensed in the State to provide maternity or pediatric care in connection with childbirth.

Note: This definition only applies to the elaws section of the Newborns' and Mothers' Health Protection Act.

A written certificate issued by a group health plan or health insurance issuer
(including an HMO) that
shows your prior health coverage (creditable coverage).
A certificate must be issued automatically and free of charge when you lose
coverage under a plan, when you are entitled to elect COBRA
continuation coverage or when you lose COBRA continuation
coverage. A certificate must also be provided free of charge
upon request while you have health coverage or within 24 months
after your coverage ends.

COBRA is a Federal law that provides rights to temporary continuation of group health plan coverage for certain employees,
retirees and family members at group rates when coverage is lost due to
certain qualifying events.

Those who are eligible may be required to pay for COBRA continuation coverage and are generally
entitled to coverage for a limited period of time (from 18 months to 36
months), depending on certain circumstances.

Health plans can generally set the terms and conditions (such as cost-sharing
and limits on the number of visits or days of coverage) for the amount,
duration, and scope of mental health benefits.
However, a plan may not impose a constructive dollar limit on mental health
benefits that is lower than that for medical/surgical
benefits. A limit on the number of visits coupled with a
maximum dollar amount payable per visit by the plan is a constructive dollar
limit.

A financial requirement that typically operates as a threshold amount that,
once satisfied, will determine whether, or to what extent, benefits are provided.
A common example of a cumulative financial requirement is a deductible that must
be satisfied before a plan will start paying for benefits. However, aggregate lifetime
and annual dollar limits are excluded from being cumulative financial requirements
(because the statutory term financial requirements excludes aggregate lifetime and annual dollar limits).

A treatment limitation that will determine whether, or to what extent, benefits are provided based on an accumulated amount. A common example of a cumulative quantitative treatment limitation is a visit limit (whether imposed annually or on a lifetime basis).

Written notification to each
qualified beneficiary of the qualified beneficiary's rights to
COBRA continuation coverage. This notice must include, among
many other things, information about the plan,
qualifying events, length of COBRA continuation coverage, and how
much a qualified beneficiary must pay for coverage and when and to whom
the payments are due. This notice should explain how long the qualified
beneficiary will have to decide whether or not to elect COBRA
continuation coverage. The
group health plan must allow at least 60 days from the date of the
notice, or from the date coverage ended, whichever is later, for a
qualified beneficiary to elect COBRA continuation coverage.

The Department of Labor has developed a
model election notice
[Spanish] that is
intended to assist plan administrators of single-employer
group health plans in
satisfying the election notice requirement. Use of this model
notice is not mandatory. However, in order to use it, a plan
administrator must appropriately add relevant information where
indicated in the model notice, select among alternative
language, and supplement the model notice to reflect applicable
plan provisions. Items of information that are not applicable to
a particular plan may be deleted. Use of the model election
notice appropriately modified and supplemented, will be
considered by the Department to satisfy the election notice
content requirements of COBRA for single-employer group health
plans.

Any labor union or organization of any kind in which employees
participate and which exists for the purpose of dealing with employers
concerning an employee benefit plan (including group health plans) or other
matters involving employment relationships. An employee organization can also be an employee
beneficiary association.

ERISA is a Federal law that
regulates employee benefit plans, such as group health plans, that
private sector employers, employee organizations (such as unions), or both, offer to employees
and their families.

The first day of coverage or, if there is a
waiting period, the first day of
the waiting period. If you enroll when first eligible for
coverage, your enrollment date is generally the first day of employment.
If you enroll as a late enrollee, your enrollment date is the first
day of coverage.

Certain benefits are always treated as excepted
benefits because they are not considered health coverage, such as:

Accident Only

Disability Income Insurance

Workers' Compensation

Other benefits are treated as excepted benefits if
they are offered separately or are not an integral part of the plan,
including:

Limited-Scope Dental or Vision

Long-Term Care Benefits

Moreover, other benefits are treated as excepted
benefits if they are offered separately and not coordinated with benefits
under another
group health plan, including:

Coverage for a Specific Disease

Hospital Indemnity or Other Fixed Indemnity

Finally, other benefits are treated as excepted
benefits if they are offered as a separate insurance policy and supplemental
to
Medicare,
Armed Forces health care coverage,
or (in very limited circumstances) group health plan coverage.

The end of your
COBRA continuation coverage because the period
of time that this coverage was available to you has lapsed, or for any
reason other than your failure to pay premiums on time or for cause (such as
making a fraudulent claim or an intentional misrepresentation of a material fact
in connection with your plan). Additional reasons for exhaustion of COBRA
coverage are possible besides the time being up. You have exhausted your
COBRA continuation coverage if the coverage ends because your employer failed to pay the
premiums on time or you no longer live or work in an HMO service area and there is no similar COBRA
coverage available to you. You need not accept a conversion policy at
the end of your COBRA coverage in order to exhaust your COBRA coverage.

Includes deductibles, copayments, coinsurance, and out-of-pocket maximums. The statute and these regulations exclude aggregate lifetime and annual dollar limits from the meaning of financial requirements; these limits are subject to separate provisions originally enacted as part of MHPA 1996 that remain in paragraph (b).

A written notice describing COBRA rights, which must be provided by the
plan administrator to
each
covered employees and covered spouse within 90 days of their beginning
coverage under the plan, or within 90 days of the plan becoming subject to
COBRA. However, if a
qualifying
events occurs and you would be required to provide an election notice before
the date the general notice is due, the general notice must be provided at the
same time as the
election
notice. Among other things, the general notice must include a
description of the COBRA coverage provided under the plan, who may become
qualified beneficiaries, and the types of qualifying events that may give
rise to the right to COBRA coverage.

The Department of Labor has developed a
model general notice
[Spanish] that is
intended to assist plan administrators of single-employer
group health plans in
satisfying the general notice requirement. Use of this model
notice is not mandatory. However, in order to use it, a plan
administrator must appropriately add relevant information where
indicated in the model notice, select among alternative
language, and supplement the model notice to reflect applicable
plan provisions. Items of information that are not applicable to
a particular plan may be deleted. Use of the model general
notice appropriately modified and supplemented, will be
considered by the Department to satisfy the general notice
content requirements of COBRA for single-employer group health
plans.

With respect to an individual, information about the individual's
genetic tests or the genetic tests of family members, the manifestation
of a disease or disorder in family members of such individual (that is,
family medical history), or any request of or receipt by the individual
or family members of genetic services.

A plan established or maintained for its employees by the Government of the
United States, by the government of any state or political subdivision thereof,
or by any agency or instrumentality of the foregoing. A governmental plan also
includes any plan to which the
Railroad Retirement Act of 1935 or 1937 applies, and which is financed by
contributions required under that Act and any plan of an international
organization which is exempted from taxation under the
International Organizations Immunities Act.

The term "gross misconduct" is not specifically
defined in COBRA or in regulations under COBRA. Therefore, whether a
terminated employee has engaged in "gross misconduct" that will justify a
plan in not offering COBRA to that former employee and his
or her family members will depend on the specific facts and circumstances. Generally,
it can be assumed that being fired for most ordinary reasons,
such as excessive absences or generally poor performance, does not
amount to "gross misconduct."

An employee benefit plan established or maintained by
an employer or by an
employee organization (such as a union), or both, that provides
medical care to employees and their dependents directly or through
insurance, reimbursement or otherwise.

Legal entity consisting of participating medical
providers that provide or arrange for care to be furnished to a given population group for a fixed fee
per person. HMOs are used as alternatives to traditional indemnity plans.

An insurance company, insurance service, or insurance organization (including
an HMO) that is
required to be licensed to engage in the business of insurance in a State and
that is subject to State law that regulates insurance.

A plan exclusion which is not designated as a
preexisting condition exclusion, but nonetheless satisfies the definition of
a preexisting condition exclusion. Examples include a provision that provides
coverage for accidental injury only if the injury occurred while covered under
the plan; a provision that counts benefits received under prior health coverage
against a lifetime limit; and a provision that denies benefits for pregnancy
until 12 months after an individual becomes eligible for benefits under the
plan.

HIPAA is a Federal law that limits
pre-existing condition
exclusions, permits special enrollment
when certain life or work events occur, prohibits discrimination against
employees and dependents based on their health status, and guarantees
availability and renewability of health coverage to certain employees and
individuals.

Benefits under a plan that are guaranteed under a contract or policy of
insurance issued by a health insurance issuer. For
information on whether your plan is insured, contact your plan administrator or
consult your
SPD. Plans that do nor meet this definition may be self-insured.

With respect to benefits under a group health plan or health insurance
coverage, a dollar limitation on the total amount that may be paid with respect
to such benefits under the plan or health insurance coverage with respect to an
individual or other coverage unit.

A disease, disorder, or pathological condition is manifested when an individual has been or could reasonably be diagnosed by a health care professional with appropriate training and expertise in the field of medicine involved. A disease, disorder, or pathological condition is not manifested if a diagnosis is based principally on genetic information.

Benefits with respect to mental health services, as defined in the terms of
the plan or coverage (as the case may be), but does not include benefits with
respect to treatment of substance abuse or chemical dependency.

Benefits with respect to services for mental health conditions and substance use disorders, as defined under the terms of the plan and in accordance with applicable Federal and State law. These regulations further provide that the plan terms defining whether the benefits are mental health or substance use disorder benefits must be consistent with generally recognized independent standards of current medical practice. This requirement is included to ensure that a plan does not misclassify a benefit in order to avoid complying with the parity requirements.

MHPA is a Federal law that requires annual
or lifetime dollar limits on mental health benefits provided by a group
health plan to be no
lower than the annual or lifetime dollar limits
for medical
and surgical benefits offered by that plan. MHPA applies to employers with
more than 50 employees.

NOTE:The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
requires group health plans and health insurance issuers to ensure that
financial requirements (such as co-pays, deductibles) and treatment
limitations (such as visit limits) applicable to mental health or substance
use disorder (MH/SUD) benefits are no more restrictive than the predominant
requirements or limitations applied to substantially all medical/surgical
benefits. For more information on MHPAEA, see the
fact sheet.

A plan maintained pursuant to one or more collective bargaining agreements
between one or more
employee organizations and more than one employer, to which more than one
employer is required to contribute.

An employee welfare benefit plan, or any other arrangement (other than an
employee welfare benefit plan), which is established or maintained for the
purpose of offering or providing any welfare benefits, such as medical,
surgical, or hospital care or benefits, to the employees of two or more employers (including one or more self-employed
individuals), or to their beneficiaries, except that
the term does not include any such plan or other arrangement that is established
or maintained under or pursuant to one or more agreements that the Secretary of
Labor finds to be collective bargaining agreements, by a rural electric
cooperative, or by a rural telephone cooperative association. For more
information see MEWA:
A Guide to Federal and State Regulation and
Filing The M-1 Form -
Qs & As.

The Newborns' Act is a Federal law that prohibits group
health plans and
insurance companies (including HMOs) that cover
hospitalization in connection with childbirth from restricting a mother's or newborn's benefits for such
hospital stays to less than 48 hours following a vaginal delivery or 96 hours
following delivery by cesarean section, unless the attending doctor, nurse
midwife or other
licensed health care provider, in consultation with the mother, discharges earlier.

Any employee or former employee of an employer, or
any member or former member of an employee organization, who is or may become
eligible to receive a benefit of any type from an employee benefit plan which
covers employees of such employer or members of such organization, or whose
beneficiaries may be eligible to receive any such
benefit.

The plan administrator is a person specifically
designated by the terms of the plan. If the plan does not make such a
designation, then the
plan sponsor is generally the plan administrator. In the case of a
plan for which an administrator is not designated and a plan sponsor
cannot be identified, the administrator may be a person prescribed in
regulations by the Secretary of Labor.

A limitation or exclusion of benefits for a condition
based on the fact that you had the condition before your
enrollment date in the
group health plan. A pre-existing condition exclusion may be applied
to your condition only if the condition is one for which medical advice,
diagnosis, care or treatment was recommended or received within the 6
months before your
enrollment date in the plan. A pre-existing condition exclusion
cannot be applied to pregnancy (regardless of whether the woman had
previous coverage), or to
genetic information in the absence of a diagnosis. A pre-existing
condition exclusion also cannot be applied to a newborn or
a child who is adopted or placed for adoption if the child has
health coverage within 30 days of birth, adoption or placement for
adoption and does not later have a
significant break in coverage. If a plan provides coverage to you
through an
HMO that has an
affiliation period, the plan cannot apply a pre-existing condition
exclusion. A pre-existing condition exclusion can not be longer than 12
months from your enrollment date (18 months for a
late enrollee). A pre-existing condition exclusion that is applied
to you must be reduced by the prior
creditable coverage you have that was not interrupted by a
significant break in coverage. You may show creditable coverage through
a
certificate of creditable coverage given to you by your prior plan
or insurer (including an HMO) or by other proof. The plan can apply a
pre-existing condition exclusion to you only if it has first given you
written notice. If your plan has both a
waiting period and a pre-existing condition exclusion, the exclusion
begins when the waiting period begins. In some states, if plan coverage
is provided through an insurance policy or HMO, you may have more
protections with respect to pre-existing condition exclusions.

The period of time that a group health plan can legally limit your access to
the health benefits offered by that plan because of a
pre-existing condition. Under
HIPAA, the maximum pre-existing condition exclusion
period that can be applied to an individual is 12 months (18 months for late enrollees).

Certain events may entitle a
qualified beneficiary who is receiving an 18-month maximum period of
COBRA coverage to an 18-month extension of COBRA coverage (for a total maximum
period of 36 months of COBRA coverage). These events are: the death of the
covered employee; the divorce or legal separation of the covered employee and
spouse; the covered employee's becoming entitled to Medicare (Medicare
entitlement of a
covered
employee is not a second qualifying event for a qualified beneficiary
unless the Medicare entitlement would have resulted in a loss of coverage under
the plan for the qualified beneficiary.); or a loss of dependent child status
under the plan. The second event can be a second
qualifying
event only if it would have caused the qualified beneficiary to lose
coverage under the plan in the absence of the first qualifying event.

Generally, a significant break in coverage is a period
of 63 consecutive days during which you have no
creditable coverage. In some states, the period is longer if your
plan coverage is provided through an insurance policy or
HMO.
Days in a
waiting period during which you had no other health coverage cannot
be counted toward determining a significant break in coverage.

An important document that the
plan administrator
must automatically provide to participants which explains
what coverage the plan offers, how the plan operates and the rights and
responsibilities of participants and beneficiaries. A SPD also must be given to participants
and beneficiaries upon request. Each plan's SPD is different. If you need a copy of the SPD, contact your plan administrator.

The opportunity to enroll in a
group health plan when certain work or life events occur, regardless
of the plan's regular enrollment dates. Generally, if certain conditions
are met, special enrollment is available when you, your spouse or your
dependents lose other coverage (including
exhaustion of COBRA continuation coverage), when you marry or when
you have a new child by birth,
adoption or placement for adoption. The plan must give you at least
30 days--from the loss of coverage or from the date of the marriage,
birth, adoption or placement for adoption--to request special
enrollment. The maximum
pre-existing condition exclusion that may be applied to a person
upon special enrollment is 12 months (reduced by the person's prior
creditable coverage). However, if enrolled within 30 days of birth,
adoption or placement for adoption, children may be exempt from any
pre-existing condition exclusion. A description of a plan's special
enrollment rules must be given to the employee on or before the time the
employee is offered the opportunity to enroll in the plan.

With respect to group health plan coverage, rules for and determinations of eligibility (including enrollment and continued eligibility), computation of premium or contribution amounts, and application of preexisting condition exclusions.

The period that must pass before an employee or dependent is
eligible to enroll (becomes covered) under the terms of the
group health plan. If the employee or
dependent enrolls as a late enrollee or on a
special enrollment date, any period before
the late or special enrollment is not a waiting period. If a plan has a waiting
period and a pre-existing condition
exclusion, the pre-existing condition exclusion period begins when the
waiting period begins. Days in a waiting period are not counted toward
creditable coverage unless there is other
creditable coverage during that time. You should try to maintain creditable
coverage during a waiting period to reduce any pre-existing condition exclusion
that may apply. Days in a waiting period are also not counted when determining
a significant break in coverage.

Any plan, fund, or program established or maintained by an employer or
employee organization, or by both, to provide participants and their
beneficiaries, through the
purchase of insurance or otherwise, with certain benefits, including medical,
surgical, or hospital care or benefits.